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Introduction to Payor EnrollmentSession Code: WE10Time: 10:30 a.m. – 12:00 p.m.Total CE Credits: 1.5Presenter: Donna Goestenkors, CPMSM and Dina Solis
Introduction toPayor EnrollmentOctober 7, 201510:30am-12:00pmDonna Goestenkors, CPMSMand Dina SolisAnswersto yourEnrollmentQuestions2Session Objectives Payor Enrollment as a career path for MSPs! Understand the basic principles of Enrollment. Top 10 Enrollment mistakes. Enrollment success tips.31
PREPARE YOURSELF4Questions From The MSP Field “Is this my future?” “What if I’m unhappy inmy job?” “What should I do if I’mseeking a new challenge?” “What’s involved?” “Do I have the skills?”5MSP Career FactsTransferrable Skills: Detail orientedUnderstand licensure requirementsIdentify red flagsDoctor FBICustomer ServiceRegulations interpretationDeadlines62
Is Payor Enrollment for Me?Enrollment is an Industry Career Path!Current Position Titles:Payor Enrollment SpecialistPayor Enrollment ManagerDirector, Payer EnrollmentVice President, Payer ServicesChief Enrollment Officer7MSP ValueEnrollment Management Federal requirements Health plan requirements Resources Technology Stakeholder satisfaction8Getting Started Enrollment is a part of the Medical Staff ServicesIndustry. Embrace the change! Reach out to a mentor. Have a career plan!!93
10What Is It Called? Let’s Brand It! Payor Payer Provider Enrollment Contracting Credentialing11Differences BetweenCredentialing Process by which each insurance company verifiescredentialsContracting Process of making a provider a participant in thenetwork124
Payor EnrollmentEnrollment is the process of applying to healthinsurance plans/networks for inclusion intoprovider panels to bill and be paid for servicesrendered.13Types of Enrollment Federal & State Medicare/Medicaid Tricare Private/Commercial Blue Cross/Blue Shield, Aetna, United Healthcare, etc. Workers’ Compensation US and State Departments of Labor Various Workers’ Comp MPNs, Plans and PPO Networks14Who To EnrollIndividual Provider vs. Group Provider Enrollment Depends on who the billing will go through (Individual NPIor Group/Org Tax ID). If enrolling Group, individual needs to also be enrolledand benefits are normally assigned to the Group. Identify your organization’s internal enrollment processes(if any!) before starting. Identify desired health plans to enroll in.155
Two Steps Pre-Enrollment Post-Enrollment16What is the Process?Pre-Enrollment Step 1 – Determine Which Plans to Enroll. Step 2 - Collect Provider Info & Documents. Step 3 - Obtain, Complete & Submit Application. Step 4 – Follow up Until Determination is Made.17Pre-EnrollmentStep 1 – Determine Which Plans to Enroll Pre-determined based on group/hospital etc.? If not, resources (AIS Directory of US Health Plans). Go to payor’s website, call Provider Enrollment forenrollment timeframe, any special requirements orforms, and preferred submission method/address.186
Pre-EnrollmentStep 2 – Collect Provider Info & Documents Pre-application, CAQH, NPI registry, repository. Review/QA for completeness/accuracy. Check addresses, zip codes and counties on USPS website. Check names/addresses/expiration dates on licensure andsupporting documents.19Pre-EnrollmentStep 3 - Obtain, Complete & Submit ApplicationApplication Elements Instructions (great reference for most questions!) Provider Identifying Information, Education, Training Provider Licensure, Certifications, Affiliations Provider References & Work History Practice Information/Description/Services Professional Liability Insurance20Pre-EnrollmentStep 3 - Obtain, Complete & Submit ApplicationApplication Elements (Continued) Billing Info/Clearinghouse/3rd Party Administrator Attestation Questions/Disclosures Ownership/Controlled Interest Disclosure Information Release/Acknowledgements Provider Agreement(s)/ EFT Agreement Checklist of Attachments217
Typical Application Attachments Required All applicable Professional, Medical, Federal, State, &Local Licensure, Certifications, Registrations. IRS Issued CP575 & Signed/Dated IRS W9. Articles of Incorporation/Partnership Agreement, etc. Professional Degree, Fellowship, Residency, CEU, DL/Pic. Professional & General Liability; Workers Comp (if app). Copy of Voided Check (for EFT agreement). Copy of Lease Agreement for Practice Location (CA). Application Fee (if applicable). Cover Letter (for paper applications).22Pre-EnrollmentStep 4 – Follow up Until Determination is MadeCommunication, Communication! Follow up with payor (email, phone, fax). Respond promptly to any requests for more info. Give updates to provider or supervisor/log into system. If approved, you may need to ask for an acceptance/welcomeletter, or duplicate letter. If denied, ask why and when to re-apply.23Highlights Pre-Enrollment 4 Steps Contact Provider Enrollment or Provider Relations Refer to each payor’s website for guidance Process Forms Requirements Processing Timeframe Submission Method Key Contacts248
Post-EnrollmentStep 1 – Obtain Proof of Enrollment/DenialStep 2 – Implement with Billing Department Assist with any applicable EFT, EDI, ERA paperwork.Step 3 – Record/Load New Contract in Database Executed copies; welcome letter; ensure provider isloaded into payer network system.Step 4 – Maintenance for Continued Enrollment Send any changes/updates/lics. to payor; re-attest.25Highlights Post-Enrollment 4 Steps Obtain proof of enrollment/denialImplement with billing departmentRecord/load new contract in databaseMaintain for continued enrollment26Reality279
TOP 10 LIST!Learn the Top 10 Enrollment Mistakesand How to Avoid Them.2829NUMBER3010
Enrollment Mistake #10Not Submitting the Correct Application(s) for theProvider Type Applications similarly Named/numbered/lettered CMS “855” Forms State Medicaids (“DHCS ”; “MAD ”;“KMAP ”) Forms to use depend on the billing entity Individual NPI vs. Group NPI (CMS 855I, CMS 855B) Reassignment of Benefits (CMS 855R)31NUMBER32Enrollment Mistake #9Not Submitting the Current Versions of PaperApplications If using paper application, be sure to download/usethe most current version.3311
NUMBER34Enrollment Mistake #8Not Submitting a “Complete” Application Leaving some areas completely blank Not indicating N/A Not including all of the required documents Application fee (applicable to the provider type)Provider AgreementEFT AgreementDisclosure of Ownership/Controlled InterestProvider Affidavit/AttestationNotary35NUMBER3612
Enrollment Mistake #7Submitting an Application that Contains Errors Omissions Typos Illegible handwriting Copies that are too light/dark; cut off37NUMBER38Enrollment Mistake #6Not Submitting the Required SupportingDocumentation/Attachments Licensing/Registrations/NPI/Signed IRS W9Original Signature PagesAdditional Provider AgreementsCover letter including ATN (Application Tracking #)or DCN (Document Control #) on each page ofattachment, if required by payor3913
NUMBER40Enrollment Mistake #5Submitting Supporting Documents that Are expiredHave inaccurate street addressHave typo(s) in name of businessHave typo(s) in name of license holder41NUMBER4214
Enrollment Mistake #4Not Ensuring that the Provider/Entity Legal NameStated on the Application Exactly Matches IRS Legal Entity NameName on IRS W-9NPPES RegistryLicenses/Registrations43NUMBER44Enrollment Mistake #3Failing to Respond Timely to Requests from thePayor for: Additional information Additional documentation Correction of any errors/omissionsSide Tips on: Contact Person Mailing Address4515
NUMBER46Enrollment Mistake #2Not Signing/Dating the Paper Application Submit wet ink signature when required Be aware of when stamped/copied/faxedsignatures are acceptable47NUMBER4816
Enrollment Mistake #1Underestimating How Long the EnrollmentProcess Actually Takes Enrollment Times Vary Greatly by Payor Status Updates/Communicate From payorTo providerTo supervisorEnter into system4950Provider RelationsKey Success Tips Get to know your provider representative byname. Use your skills as a Leader to impact the process. Stay actively connected to maintainrelationships, facilitate information flow andtrouble-shoot. THANK them, frequently. Connect with them on LinkedIn.5117
Success Points Begin the enrollment process immediately uponcollecting information. Automate the enrollment process to the greatestextent possible: IntelliSoft, symplr (formerlyMedkinetics), CAQH, database software, Morrisey,HealthLine Systems, Cactus, etc. Minimize the use of paper forms whenever possible. Respond to payor requests as soon as possible! Communicate proactively with providers!52TOP 10 SUMMARY1.2.3.4.5.6.7.8.9.10.Use the CORRECT forms for the provider type.Use only CURRENT versions of paper applications.Submit a COMPLETE, ACCURATE, fully LEGIBLE application.Include ALL of the required application attachments.Submit a COVER LETTER with each application/supportingdocument package. Include applicable ATN, DCN, coverpage.Ensure supporting documents are not EXPIRED and haveCORRECT name and street address of the licensee.Ensure the legal name on application MATCHES EXACTLY tothe IRS document, IRS W-9, NPPES, and licensee names.Respond PROMPTLY to payor requests for additionalinfo/documents. Ensure appropriate Contact Person/Address.Ensure the application and agreements are PROPERLY signed.Effectively COMMUNICATE each payor’s processing times andprovide REGULAR UPDATES to stakeholders.53Utilize Your ResourcesApplications, applications and more applications!Credentialing software can help automate the application process by autopopulating, tracking, and even submitting applications IntelliSoft, Sy. Med, Morrissey, Cactus, symplr, etc. Some plans have auto-fillable forms you can download from their website Credentialing software can help automate the application process by autopopulating, tracking, and even submitting applications For paper applications, urge your organization to obtain the full version AdobeAcrobat Pro. No handwriting!5418
Even More Resources & Tips Take the time to accurately enter provider data on applications and in CAQHand software. Electronically Save, Re-Name, and Upload provider’s credentialing documentsseparately ahead of time. No bundled docs! Audit your work. Twice!55Primary ResourceAIS (Atlantic Information Services Directory of HealthPlans 2015) Comprehensive directory of all US health plans with member enrollment,plan type, demographic and contact information. Print, CD, and USB Flash Drive database formats. Website: www.aishealth.com for purchase information.56Hands On TrainingNational Provider Enrollment Workshop Dec 7-9, 2015 Dallas, TX Decision Health www.decisionhealth.com Early Bird Registration Ends Oct 15th ( 200 off)5719
POWER THOUGHT“Your resources are always far greater than youimagine them to be. Never ask, ‘Can I do this?’Ask instead, ‘How can I do this?” Dan Zadra - Author58Speaker Contact InformationDonna Goestenkors, CPMSM Team Med Global Consulting, LLC Donna@teammedglobal.com Telephone: (618) 830-0057 Website: www.teammedglobal.com Like Me: www.facebook.com/teammedglobal Connect with Me: www.linkedin.com/donnagoestenkors Follow Me: www.twitter.com/teammedglobal59Speaker Contact InformationDina Solis, Owner Sonoma Credentialing Services P.O. Box 4661 Petaluma, CA 94955-4661 Dina@sonomacredentialingservices.com Telephone: (855) 707-9995 Website: www.sonomacredentialingservices.com Like Me: www.facebook.com/SonomaCredentialingServices Connect with Me: www.linkedin.com/in/dinasolis6020
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Credentialing software can help automate the application process by auto-populating, tracking, and even submitting applications IntelliSoft, Sy. Med, Morrissey, Cactus, symplr, etc. Some plans have auto-fillable forms you can download from their website Credentialing software can help automate the application process by auto-
